GLP-1 receptor agonists and SGLT2-inhibitors in patients with diabetes and ischaemic heart disease in primary care

Abstract Background Glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) are recommended in ESC guidelines as first-line drugs for patients with type 2 diabetes (T2D) and concomitant ischaemic heart disease (IHD), before metformin and irrespective of blood sugar levels. However, little is known about the usage of GLP-1 RA and SGLT2i in primary care among patients with T2D and IHD. Purpose We examined GLP-1 RA and SGLT2i usage in primary care among patients with T2D and concomitant IHD, and assessed variations by sex, age, and across different primary healthcare centres (PHCCs), including differences between private and public ownership. Methods Cross sectional study from a primary care register in a large Swedish region (population 1.8 million). All 210 PHCCs in the region report monthly individual data to the register regarding patients with a registered diagnosis of T2D and IHD. Dispensed drugs up to 120 days before 1 September 2023 were retrieved from the regional prescribed drug register. Ordinary and multilevel regression models were used to test for differences in drug dispensation by sex and age, and between different PHCCs by estimating odds ratios (OR) and adjusted median odds ratios (MOR) with 95% confidence intervals (CI). The multilevel model included sex, age, comorbidities, PHCCs, and PHCC characteristics (including private/public ownership). Results The study included 14 414 patients with T2D and concomitant IHD (age 74.4 ± 10.0 years, HbA1c 52.8 ± 12.5 mmol/mol, 30.6% women). Overall, GLP-1 RA were dispensed to 10.0%, and SGLT2i to 37.2% of the patients. (GLP-1 RA and/or SGLT2i: 42.1%). The proportions of patients with dispensed drugs across sex and age are presented in Figure 1A and B. The prevalences of GLP-1 RA and SGLT2i were highest among young patients and decreased with age (p0.001 for trend). There was no difference in dispensed GLP-1 RA in women compared to men 9.2% vs. 10.4%, age adjusted OR 1.04 (95% CI 0.92–1.18), whereas SGLT2i were dispensed less often to women compared to men 28.8% vs. 39.9%, age adjusted OR 0.64 (0.59–0.70). The proportion of patients with dispensed GLP-1 RA and SGLT2i varied between 0%–27.3%, and 0%–68.4%, respectively, between different PHCCs (Figure 2A and B). The adjusted MORs between different PHCCs were 1.48 (1.37–1.62) for dispensed GLP-1 RA, and 1.29 (1.23–1.36) for SGLT2i. No differences in dispensed drugs were seen regarding private vs. public PHCCs GLP-1 RA OR 1.07 (0.90–1.26); SGLT2i OR 0.97 (0.87–1.08). Conclusions GLP-1 RA and SGLT2i were underutilized in patients with T2D and concomitant IHD in primary care relative to ESC guidelines. Addressing the sex disparity in SGLT2i usage is warranted. It is also desirable to reduce the significant and large variation in dispensation of GLP-1 RA and SGLT2i between different primary health care centres, particularly by increasing usage in centres with the lowest dispensation rates.Figure 1 Figure 2